While children may not be the most visible victims of COVID-19, the pandemic has undoubtedly taken a toll on their well-being. The disruption of in-person activities such as school, socialization and sports significantly impacts children’s mental health, and many children have also become seriously ill or lost a loved one due to COVID-19.

To discuss children’s health during the COVID-19 pandemic, Jodie Guest, PhD, professor and vice chair of the department of epidemiology at Emory’s Rollins School of Public Health, spoke with Lee Beers, MD, president of the American Academy of Pediatrics. Beers, an Emory University School of Medicine alum, is also the medical director for Community Health and Advocacy at Children’s National Hospital in Washington D.C.

Their conversation is part of an online video series hosted by Guest, who leads the Emory COVID-19 Outbreak Response Team, addressing topics related to the COVID-19 pandemic. Watch the full conversation here. 

Q: Why are pediatric cases of COVID-19 continuing to rise?

A: While there have been fewer cases of COVID-19 reported in children than among adults, Guest notes that 6 million children in the U.S. have been diagnosed with COVID-19 over the course of the pandemic, “including 135,000 cases just this past week.” Pediatric cases of COVID-19 have steadily risen since August.

There are several reasons for this rise in pediatric cases, Beers says. “First is that children and adolescents are a larger percentage now of our unvaccinated population in the United States, so they’re really the group who are most vulnerable to being infected, because they’re the ones who don’t have the protection of the vaccine,” she says. “The second reason is with the Delta variant, that has been much more transmissible, and so it does spread much more quickly in places like big group gatherings, or schools, or things like that when children and adolescents aren’t using good and safe mitigation measures. So, I think a combination of those two things has led to a real increase in cases across the country – and particularly in places where immunization rates are lower.” 

Q: What puts a child at greater risk of severe illness from COVID-19?

A: Children with disabilities and health care needs that impact the functions of the lungs or heart are at higher risk for severe outcomes from COVID-19, Beers says. Children with obesity are also at higher risk.

However, Beers cautions that even previously healthy children are at risk for severe illness, noting that between one-third to one-half of children hospitalized with COVID-19 have no underlying medical conditions. “I think that’s another really important thing to remember – that certainly there are conditions where children are at higher risk for more severe complications of COVID-19, but, actually, previously healthy children are, as well,” she says. “And we want to keep all our children safe.” 

Q: What is MIS-C and how does it affect children with COVID-19?

A: Some children infected with COVID-19 have developed a rare condition called multisystem inflammatory syndrome in children (MIS-C). “There have been a little over 5,200 cases of this syndrome in children and 46 associated deaths in the United States,” Guest says. “These numbers have increased across the pandemic.”

“It is an uncommon syndrome, which is a good thing,” Beers says, “but also, a small percentage of a large number of children ends up being a large number of children, right?” In communities with high rates of COVID-19 transmission, more children are at risk of infection and complications from COVID-19 like MIS-C. 

Because the syndrome is multi-system, it can cause anything from serious heart and lung problems to issues with digestion and neurologic functions. “So, kind of a wide range of things that we can see,” Beers says. “It often is pretty serious in kids and can last for some period of time, and cause challenges for kids.”

Q: What are symptoms of MIS-C that parents should watch out for?

A: “In many ways, it’s the same answer that we would give to lots of things,” Beers says. Parents should watch out for children who feel unwell, are unable to participate in their usual activities or tire easily. “I’m a parent too. I know you know when there’s something off with your child, and so if something seems really off, that is a really important reason to give your pediatrician a call to take a look, because it can actually be a little bit difficult to diagnose.” 

MIS-C can occur in both children who tested positive for COVID-19 and children who had asymptomatic infections and were never tested, adds Guest. 

Q: If COVID-19 vaccines become available for children ages 5 through 11, will they be safe?

A: “The safety and efficacy review that the FDA goes through is incredibly cautious and rigorous and careful, and so I feel very confident that anything that’s authorized by the FDA is a safe and effective vaccine,” Beers says. “They’re incredibly cautious with adults, and then there’s an extra layer of caution added with kids. The vaccines that are authorized to date for adolescents ages 12 and up and in adults are very safe and effective, and I have every confidence that if, and when, the FDA authorizes a vaccine for younger children, it will be safe for them, as well.”

An independent panel of FDA advisors met on Oct. 26 (after this interview occurred) to consider whether to grant emergency use authorization (EUA) of Pfizer’s COVID-19 vaccine for children ages 5 through 11. After reviewing data from a study of 1,518 children who participated in clinical trials, the panel voted in favor of authorizing the Pfizer vaccine for this age group; however, vaccinations won’t become available until the Centers for Disease Control and Prevention and its advisory group have issued their own recommendations. 

Q: Will vaccines help curb pediatric cases of COVID-19?

A: Because most young children are unvaccinated, they remain among the most vulnerable to COVID-19. If these children become eligible for vaccination, they will be at less risk of developing illness from COVID-19 and spreading the virus in their communities. 

“So, I do think it’s an important part of helping to get the pandemic under control and helping to protect those around us – helping to protect adults who are vaccinated but are immunocompromised, or young babies who still don’t have access to the vaccine,” Beers says. “I would also add, as a parent, this is always important to know and remember — that it’s also really important protection for your child. Vaccinating your child with a safe and effective vaccine has benefits for the community, but it also has really, really important benefits for your child.”

Q: Will the vaccine for children be the same as the vaccine for adults?

A: “It is definitely the same vaccine,” Beers says. Because children’s immune systems work differently than those of adults, vaccines for children are often administered in a smaller dose. “You want to make sure you’re using the lowest possible dose of the vaccine to be most effective,” Beers says. “When we think about dose of vaccines, it’s related to the maturity of the immune system as opposed to weight. That’s another question that parents ask a lot: ‘My 11-year-old is bigger than my 13-year-old, so why is there a different dose?’ But it’s really about the age and maturity of the immune system.”

Based on data from the most recent pediatric clinical trials, researchers determined that one third of a regular dose of Pfizer’s COVID-19 vaccine is safe for children ages 5 through 11. If approved for use, the vaccine for this younger age group will also be packaged differently. “To make sure the vaccine is administered safely and everything is very clear, the vaccine is going to be packaged in a vial that looks a little bit different, so it will be easy to determine which is the vaccine for the adult dose and which is the vaccine for the pediatric dose,” Beers says. “It is the exact same vaccine, just a slightly smaller dose.” 

Q: Where will young children go to receive their COVID-19 vaccines?

A: Beers says that pediatrician’s offices will play an important role in administering COVID-19 vaccines, and that surveys have shown this is where parents feel most comfortable taking their young children for vaccination.  “I think that makes sense, right? Because it means that there’s someone who they can ask their questions to, that they know is a place that’s used to giving vaccines to younger kids, and so they know how that all works,” Beers says. 

“I also think clinics at schools are another important place, because, again, it’s a place where your kids feel comfortable, you know that they’ve developed the partnerships to be able to offer that to you, so I think it is important,” she continues. 

If vaccines for children ages 5 through 11 are approved, Beers stresses the importance of patience among parents eager to vaccinate their children. “It may take a couple days after the vaccine is recommended to be able to get these new vials out to all the places that are going to be distributing it – and also knowing that your pediatrician’s office is working as absolutely hard as they can to make the vaccine available to you, but they’re also testing kids for COVID and seeing lots of sick kids. So, just a reminder to parents to show a little grace, know that we’re all working as hard as we can to be able to be able to make the vaccine available,” she says. 

Q: Why have other childhood vaccinations declined during the pandemic?

A: “Over the course of the pandemic our rates of what we call ‘routine childhood immunizations’ – which basically means the ones that we’ve been getting all along – has decreased pretty significantly,” Beers says. 

“A lot of that’s been about lack of access to pediatrician’s offices and schools not being in session, and so those requirements were perhaps not there,” Guest says.

While COVID-19 has taken precedence, other illnesses have not disappeared during the pandemic. Therefore, it is important for children to stay up to date on their regular vaccinations.

“It’s also the time of year to get your flu shot, so you want to get your flu shot as well. That’s another good reason why we’re really glad that the COVID vaccine is going to be made available to pediatricians’ offices – to make it easier for families, so that they can come and get caught up on everything and do it all in the same place, at the same time,” Beers continues. “I encourage families to reach out to their pediatrician’s office if they are due for a checkup, or even if they’re not sure, to just check in and see, ‘Are there any other shots that I’m due for?’”

“There’s going to be a lot of fun Band-Aids your kids are going to leave the pediatrician’s office with,” Guest adds.

Q: Should parents be concerned about the risk of myocarditis after vaccination?

A: Some young people have experienced myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart) shortly after receiving a second dose of the Pfizer or Moderna vaccines. For 16- and 17-year-old boys who are vaccinated, the risk of developing these conditions could be around 1 in 5,000, according to results from an analysis of Pfizer data published by the FDA in August.

“I have a 12-year-old boy, so I looked at the data both as a pediatrician but also as a mother who was going to make that decision for her own child, and I felt 100% comfortable getting the vaccine for my son,” Beers says. “Two things that were really important to me and that I share with families: first is that, actually, the risk of myocarditis or pericarditis if you get infected with COVID is significantly higher than the risk of myocarditis potentially following the vaccine.” Secondly, she says, cases of myocarditis after vaccination “have been mild cases” where children have fully recovered.

In contrast, children who acquire COVID-19 infection are more likely to develop more severe cases of myocarditis. “There’s still a range, but you see a lot more kids who are in the intensive care unit who are very seriously ill, and when we talk to our pediatric cardiologists, those are the kids that they really worry about; those are the kids that they lose sleep over, because they really are quite sick,” Beers says. 

Q: How important is in-person school for children?

A: “I think it really is essential,” Beers says. “At the American Academy of Pediatrics, this has been our stance from the very beginning of the pandemic ­— from our first guidelines about safe schools, which we released the summer of 2020 — that we should be doing everything we can to prioritize in-person learning for children.”

“The way we do that is to make the school environment as safe as possible. That absolutely means — at least at this point in the pandemic — wearing masks universally in the school, because that helps decrease spread, particularly when you have little ones who aren’t yet eligible.” Improving ventilation and maintaining physical distance when possible are also important safety measures. 

“Most schools really are back for in-person learning, and one of the things that we’ve been seeing, particularly early on in the school year, was a lot of disruption in that in-person learning, because lots of kids were getting exposed or infected and needed to go home to quarantine,” she continues. “Vaccinations and masks can dramatically decrease the need for disruption in in-person learning from that perspective, as well.” 

Q: What impact has the pandemic had on children’s mental health?

A: While the prolonged stress and isolation of the pandemic has impacted both adults and children, “as an adolescent, your brain is still growing and developing,” Beers says. “Adolescents can be more impulsive, and so that does put them at higher risk for suicidal ideation.”

“We’ve been doing a lot of work in this area because even prior to the pandemic, mental health was a serious concern,” Beers says. “Even prior to the pandemic, suicide was the second leading cause of death in children, but during the course of the pandemic we’ve really seen this dramatically worsen.”

“I think there are many reasons for that,” says Beers, including disruptions to schooling, loss of caregivers to COVID-19, lack of access to mental health services, and the stress of economic instabilities. “Children of color are disproportionately impacted by all of these things, actually in many, many ways. When we look at the number of children who have lost caregivers to COVID, a much greater percentage of those kids are children of color.” 

Q: How can we help improve children’s mental health?

A: “There’s lots of things we can do — lots of things that we know make a big difference,” Beers says. “One is making sure that we have enough mental health providers in places where kids are — schools, pediatricians’ offices, community centers, all those places. Also, making sure that for those kids who really are struggling more significantly, and who need intensive mental health treatment or inpatient treatment, that we have the beds available for them. We have to really invest in the people and the workforce and the space that’s needed to make sure that we have these services available.”

“The final thing I would add is there’s something all of us can do, even if we’re not mental health professionals, because kids thrive when they’re in communities where they have safe, loving adult relationships,” she says. ”We all interact with youth in lots of different ways, and thinking about how we can help make our communities a stronger and safer place for our young people will make a difference, as well.”